Module 4-Final

MODULE 4
INTRODUCTION TO
ADHERENCE
Goal
The goal of this module is to equip Health
Care Providers with knowledge on
Adherence in support of Care and
Treatment
Objectives
At the end of this session, the participants will
be able to
Explain the meaning and components of
adherence
Define the importance of adherence
Outline factors that influence adherence
Describe Forms and Consequences of nonadherence
Describe the strategies and tools of
monitoring adherence
UNIT I
WHAT IS ADHERENCE
What is adherence?
Adherence is the extent to which a
clients behavior matches the prescribed
health care regimen determined through a
shared decision making process
between the client and health care
provider
What is adherence?
The engagement and accurate
participation of an informed patient in a
plan of care.
It is broader than compliance.
It implies understanding, consent and
partnership.
Components of Adherence
Care and support
Nutritional support and physical exercises
Adhering to positive living
Entering into and continuing in a program
or plan of care
Attending appointments and tests as
scheduled.
Components of Adherence
Treatment
Taking medications as prescribed
Timing, Dosage, Storage requirement
Lifestyle
Modifying lifestyle as needed
Adherence vs. Compliance

Adherence: the act or quality of sticking to
something, steady devotion; the act of adhering
Acceptance of an active role in ones own

health care
Compliance: the act of conforming, yielding or

acquiescing
Lack of sharing in the decision made between

provider and client
Why is adherence support

important?
Worldwide research confirms that majority
of people undergoing long term treatment
for chronic illnesses (e.g Diabetes,
Hypertension, HIV/AIDS, etc) are nonadherent from time to time
Research Studies
More than 10% of patients report missing
one or more doses on a given day
More than 33% report missing doses in
past 2-4 weeks (Chesney et al, 2000)
However Providers cannot easily accurately
guess whether a given patient will be
adherent or not
How much adherence is required

for successful therapy?
Goal of HAART: maximal and durable viral
suppression (undetectable levels)
Successful HIV therapy requires

adherence > 95%
Failure rates increase sharply as
adherence decreases
UNIT 2
IMPORTANCE OF
ADHERENCE
Why is adherence important

How many of you have been nonadherent to medication?
Brainstorm for 10 minutes
Importance of Adherence
Adherence to ARVs is important for clinical
effectiveness
Few drug options thus limited options for
changing regimen
Improved quality of life/Ability to return to work
Poor adherence and drug

resistance
Poor adherence (or inappropriate prescribing)
results in exposure of the virus to sub-inhibitory
concentrations of ARVs
This leads to on-going viral replication and
continued CD4 destruction
It also leads to the development of resistance
Resistance to one drug may cross to other drugs
in the same class
Resistant strains can be transmitted in the
population
There is a limited choice of affordable
combinations
Who needs adherence counseling?

Everyone requires adherence counseling but not
the same intervention
Everybody will benefit including people from:
Different ages
Different educational backgrounds
Different social status
Different ethnic origin or geographical areas
Who should give adherence

messages
(Brainstorming for 10 minutes)
UNIT 3
Factors influencing
Adherence
Group activity 30 minutes
Discuss potential barriers influencing

adherence:
1.
2.
3.
4.
5.
Disease factors
Medication factors
Psychological factors
Social factors
Spiritual factors
Discuss methods on how to promote

adherence for factors mentioned above
Factors influencing Adherence

Complexity of regimen/complicated
schedule or dose frequency
Long duration of treatment/change of
lifestyle
Skepticism about treatment
Cost of regime
Confidentiality/Disclosure issues
HIV related conditions
Degree of behavior change required/safer
sex
The Complexity of adherence

Disease
characteristics
Treatment
regimen
Adherence
Patient
variables
Patient
Provider
relations
Clinical Settings
Client Contributing Factors

Understanding treatment regimen
Side effects of therapy
Mental health/Psychological factors-stress,
depression, active psychiatric illness
Stage of HIV disease
View of personal health
Cultural/religious beliefs/Misperceptions
Other basic needs e.g food
Family/caregiver/group support
Clinician contributing factors

Knowledge on treatment regimen
Knowledge on adherence
Treatment experience/expertise
Relationship with client
- Trust, interpersonal skills,
Ample time for client teaching
Disease contributing factors

Prior opportunistic infections (OI)
Severity of their earlier OIs
Adherence to medication for past illness
Other medication being taken whilst ARVs
initiation needs to be started.
WHO stage at the time of starting ARVs
Patient provider
contributing factors
Patient /provider confidence and trust
Environment of the clinic
Conducive environment
Brainstorm on forms of non

adherence
10 minutes
Forms of Non Adherence

Patient may incorrectly time the
medication or take the wrong dose
Patient may forget to completely take
dose
Patient may self-adjust due to side effects
or personal beliefs
Patient may go on drug-holiday/drug
fatigue
Sharing of medication
Missing one dose of a given drug

Missing a dose of all the three drugs
Missing multiple doses
Missing a whole week of treatment.
Not observing the time intervals
Not observing the dietary instructions

Not avoiding risky behavior- unsafe sex,
substance abuse, multiple partners
Not attending support groups
Not keeping their clinic appointments
Consequences of nonadherence
Incomplete viral suppression
Continued destruction of the immune
system and decrease of CD4 cell count
Progression of disease
Emergence of resistant viral strains
Limited future therapeutic options and
higher costs for individual and program
Influx of opportunistic infections
UNIT 5
STRATEGIES AND
TOOLS OF
MONITORING
ADHERENCE
Strategies And Tools Of Monitoring

Adherence
Brainstorm for 10 minutes
Strategies and tools of

monitoring adherence
Self reports
Pill counts
Biological markers
Pharmacy records
Treatment supporter/Buddy system/Peer
counselors
Support groups/Post test clubs
Patient diaries and cohort books
Monitoring for effectiveness

Clinical improvement
Laboratory tests
-Viral load reduction
-Increase in CD4 cell count
Quality of life (QOL) / Adherence baseline

& follow up data
Self-reports
Patients report using a 3 day, 1 wk, 1 month or most
recent recall of missing a dose
Can be done using a series of non-judgmental questions
at clinic visits
E.g.: Many people forget to take tablets sometimes when
was the last time you missed a dose?
is better than:
Do you ever forget your tablets? (Invariably the answer
will be No)
Has a tendency to over estimate
A trusting provider/patient relationship is needed
Easiest tool in clinic setting
Pill counts
Providers count remaining pills during
clinic visit
It is waste of time unless the provider also
calculates the correct number that should
remain if adherence was 100%
For pediatrics you check and demonstrate
Limitations
Patients can dump pills prior to visit
If done insensitively, it can damage the
patient-provider relationship
Biological markers of
effectiveness of treatment
A decreasing viral load implies good
adherence
But in some patients viral load may remain
high even with good adherence. In these
cases suspect:
Drug resistance
Poor absorption of the drug
Pharmacy records
Pharmacists keep record of drugs
dispensed to each patient and compares
the same to clinical records
Can inform the relevant doctor of lapses in
patients collecting their medicines (esp.
good for patients who buy their own
medicines)
Limitations
Is not a measure of ingestion
Requires patients to always use the same
pharmacy
How to promote adherence
Dont rush to ARV, patient must be ready!

Participation of the patient in a plan of care.
Counseling: Individual or in group
Information/Education/Communication on
ARV drugs:

Provide simple written information (booklet,
pamphlet, posters)
Warn patients about common side effects
Same adherence message by all health
workers/Community Health Workers
(CHWs)!!!

Buddy system (family or friend reminds
client to take medicines)
Medication Diaries, pill boxes, pill charts
Incentives (transport, food etc)
Use fixed drugs combinations (1 pill twice
a day)

Availability and affordability of ARV drugs
Directly Administered ART Therapy
(DAART) or modified Direct Observed
Treatment
Disclosure
Summary
Adherence Counseling
Knowledge
HIV disease, CD4 count
Medications side-effects
Attitudes
Positive belief and perceptions
Self efficacy and commitment
Practices and support systems
Disclosure, buddies, and family systems
Summary
Identifying and addressing barriers
Integrating treatment regimen into
patients daily routine
Encourage family involvement
Providing remainders cues
THANK YOU

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MODULE 4

Adherence vs. Compliance

something, steady devotion; the act of adhering

Acceptance of an active role in ones own

Compliance: the act of conforming, yielding or

Lack of sharing in the decision made between

Why is adherence support

How much adherence is required

Successful HIV therapy requires

Why is adherence important

Poor adherence and drug

Who needs adherence counseling?

Who should give adherence

Group activity 30 minutes

Discuss potential barriers influencing

Discuss methods on how to promote

Factors influencing Adherence

The Complexity of adherence

Client Contributing Factors

Clinician contributing factors

Disease contributing factors

Brainstorm on forms of non

Forms of Non Adherence

Forms of Non Adherence

Missing one dose of a given drug

Forms of Non Adherence

Strategies And Tools Of Monitoring

Strategies and tools of

Monitoring for effectiveness

Quality of life (QOL) / Adherence baseline

How to promote adherence

Dont rush to ARV, patient must be ready!

How to promote adherence

How to promote adherence

How to promote adherence

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